Health System Specialist GS-679-9



HEALTH SYSTEM SPECIALIST-SERVICE UNIT

GS-671-09

I. Introduction:

This position is organizationally located in the Contract Health Services (CHS) Branch, Service Unit, Indian Health Service. The purpose of this position is to provide support and technical assistance to the Service Unit management on matters involving CHS including medical, surgical, dental, hospital and clinical services to all eligible beneficiaries in conjunction with or in lieu of IHS facilities.

II. Major Duties:

Serves as the specialist responsible for evaluating and reporting on CHS services provided by the Service Unit. Investigates and analyzes controversial issues and develops drafts related to reports, correspondence and other written material. Assists in developing policies and procedures in the CHS Program.

Performs liaison functions with contract health providers, state and local agencies; and monitors/reports status of CHS activities and funds. Prepares analytical data, staff reports and memoranda which reflect utilization of CHS resources.

Issues purchase orders obligating CHS funds, then electronically submits purchase order information to the contracted fiscal intermediary for IHS. Determines those cases that patients may qualify for alternate resources and/or catastrophic health emergency funds.

Performs high cost case management of expenditures for determining those cases with catastrophic illnesses in order to request and receive reimbursement of Catastrophic Health Emergency Funds.

Participates in Quality Assurance/Utilization Review by conducting CHS Review Committee meetings.

Responsible for evaluating pertinent contract health cases and assembling, analyzing and checking statistical data. Advises patients and their families concerning eligibility and other facets of the CHS Program. Plans and develops orientation materials for patients, families, and hospital staff concerning CHS.

The incumbent considers the personal and medical factors that differ with each patient, such as economic status, educational level, medical problems, treatment methods, and progress of the patient. The specialist identifies the various factors to be considered and advises the physician on specific CHS requirements.

Offers CHS assistance to eligible Indian people within fund limitations and operates within medical priorities. Conducts on-site patient interviews to establish eligibility for IHS patients for CHS. Provides assistance to individuals applying for services from other sources including medicare, V.A., CMS and AFDC.

Initiates Medical Purchase orders to include periods of hospitalization and medical fees for professional services. Responsible for the maintenance of complete Document Control Registers indicating Government appropriated funds for Contract patient care. Informs the Chief, Financial Management and Service Unit Director of the current status of funds available on a regular basis. Recommends adjustments in medical priorities when limited funds warrant.

Reviews completed claims submitted by vendors, and EOBRS received from the FI. Returns unclear or incomplete documents to health providers. Compares services provided against contract terms, and enters data to ensure that system operations are accurate. Contacts CHS providers and explains IHS policies and contract care procedures. Establishes and maintains a cooperative working relationship with contract vendor staff.

Issues correspondence to patients, health care providers and other agencies regarding eligibility, IHS policy and regulations, including letters of denial of claims. Insures confidentiality of patient information. Maintains denial, deferred and appeals tracking for reporting.

Audits claims processed for patient eligibility for third party programs, proper codes which indicate primary provider code, diagnosis, and clinic code.

Directs the maintenance of the commitment registers, a daily log of obligations processed. Reviews automated data for comparison with manual data and when errors are detected locates the source and executes appropriate corrective action. Resolves nonstandard processing problems which subordinate staff cannot resolve. Key enters and verifies all fiscal and statistical data through use of ADP equipment.

Prepares correspondence to third-party providers to obtain data on services provided. Represents CHS in Service Unit meetings.

Performs supervisory functions including work planning and scheduling and directing as well as all Personnel Administration and management functions. Provides supervisory responsibilities over 1-3 staff members.

Performs other related duties as assigned.

III. Factors

l. Knowledge required by the position.

Knowledge of Health Care Delivery Systems.

Knowledge of Contract Medical Care policies and procedures.

Knowledge of Fiscal Intermediary claims processing procedures both electronically and manually.

Knowledge of Catastrophic Health Emergency Funds.

Knowledge of Third party billing systems.

Knowledge of IHS automated data processing system. Knowledge of supervisory methods and procedures.

Knowledge ICD-CM and CPT-4 coding.

Knowledge of specialized Medical Terminology.

Knowledge of basic accounting methods.

Knowledge of basic acquisitions and contracting methods.

2. Supervisory Controls

Work is assigned by the Supervisor who provides the incumbent with instruction of what is to be accomplished. The incumbent executes routine work assignments independently but consults the supervisor on situations which are very complex, controversial or precedent setting. Work is reviewed by conformance to policy and procedure and accomplishment of work elements in the employee's annual performance plan.

3. Guidelines

IHS Circulars/Manuals, State, Federal, and Public Laws, IHS Procedural Manual,

ICD-9-CM Code Manual, and JCAHO Accreditation Manual. Incumbent must use individual judgement the interpretation and application of these guides.

4. Complexity

The work involves processing a wide variety of transactions and compiling reports for Contract Health applications and third party billing activity. Work requires identifying transaction types, extracting, compiling and verifying payment data, computing and adjusting account balances, preparing required forms and records, and submitting and maintaining current assignment of benefits.

5. Scope and Effect

Purpose of the work is to assure maximum utilization of Contract Health funds by a comprehensive CHS eligibility determination and use of all available alternate resources and contractor contracts/agreements. This work generates approximately percent of all Service Unit income and expenditures.

6. Personal Contacts

A wide variety of contacts are made. This includes patients and families, direct medical providers, contract providers and vendors, insurance carriers, tribal and community agencies and various other Federal, State and Local agencies.

7. Purpose of Contacts

Contacts are made with patients and families and providers to obtain medical data and information and to explain IHS Contract Health Care policies and procedures and to determine Contract Care eligibility. Contacts with Contract vendors is to negotiate cost equities and fulfillment of contract provisions. Contact with third party carriers is for the purpose of exchanging information and resolution of payment disputes.

8. Physical Demands

The work is located in a health care facility with some walking and movement through the hospital and prolonged sitting.

9. Work Environment

Work is generally performed in an office setting.

EVALUATION STATEMENT

Position: Health System Specialist, GS-671-09

Organizational Location: Contract Health Services, IHS Service Unit.

Reference: OPM PCS for Health System Specialist, GS-671 series 12/79;

OPM PS for Management and Program Analysis, GS-343 Series 8/90;

HHS Guide for Contract Health Positions 1/94.

Title/Series Determination:

Subject position assignments require a knowledge of the basic practices and principles related to Health Care Delivery System Management. This type responsibility is characteristic of work included in the series definition of the cited GS-671 series which is allocated.

Grade Level Determination:

Subject position is classified by direct application of Administrative Analysis Grade Evaluation Guide as depicted on the FES position evaluation statement. Supervisors may request the FES evaluation from Headquarters-CHS.

Conclusion: Health System Specialist, GS-671-09.

/s/

Vernon E. Hohmann

Position Classification Specialist April 5, 1994

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